Healthcare Provider Details

I. General information

NPI: 1396851465
Provider Name (Legal Business Name): STACEY BRIDGES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 RAINBOW DR UNIT 35
PINEVILLE LA
71360-6979
US

IV. Provider business mailing address

3319 MARYE ST
ALEXANDRIA LA
71301-4820
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-5191
  • Fax:
Mailing address:
  • Phone: 318-443-4587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number260018
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: